4.2 Labor interventions
The care a mother experiences during labor and birthing can affect breastfeeding and how she cares for her baby. Birth practices that help the mother to feel competent, in control, supported and ready to interact with her baby include:
- Emotional support during labor
- Freedom of movement during labor
- Offering light foods and fluids during labor
- Avoidance of unnecessary caesarean section
- Early mother-infant contact
- Facilitating the first feed
When labor interventions are considered factor in the following information.
Analgesia during labor
The most commonly used intrapartum analgesics are potent narcotics, all of which are known to cause sedation and respiratory depression in the mother and the baby, and also to affect behavior.
- Morphine has a short half-life (1.5 - 2 hrs) and does not have an active metabolite
- Butorphanol (Stadol) has a half-life of 3 - 4 hours.
- Nalbuphine (Nubain) has a half-life of 5 hours.1
- Meperidine (Pethidine/Demerol) is metabolized to the active metabolite normeperidine (norpethidine) which has a long half-life (63 hours in the neonate). Meperidine/Pethidine reaches its highest levels in the fetus 2 to 3 hours after administration, however normeperidine/norpethidine levels continue to rise the longer it is until birth. Normeperidine/norpethidine still has half the pharmacological activity of meperidine/pethidine.
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![]() | ![]() How long will the effects of meperidine/pethidine be experienced by the newborn baby?It takes approximately 5 half-lives for a substance to reach insignificant serum (blood) concentration. How long will it take the newborn baby to clear normeperidine and its effects from his system? Multiply 63 hours by 5 times; then divide by 24 to have your answer in days. | ![]() |
- Shorter-acting opiates such as fentanyl are preferred. Remifentanil is potent and has rapid onset and offset but can be associated with a high incidence of maternal apnea, requiring increased monitoring. Its transfer in utero to the fetus is minimal.
- Meperidine/pethidine generally should not be used except in small doses less than 1 hour before anticipated delivery because of greater incidence and duration of neonatal depression, cyanosis, and bradycardia.
- Nalbuphine, butorphanol, and pentazocine may be used for patients with certain opioid allergies or at increased risk of difficult airway management or respiratory depression. However, these medications may interfere with fetal heart rate monitoring interpretation. Observe the mother and infant for psychotomimetic reactions (3%).
- Multiple doses of intravenous analgesic, and their timing of administration may lead to greater neonatal effects. For example, fentanyl administration within 1 hour of delivery or meperidine/pethidine administration between 1 and 4 hours before delivery is associated with more profound neonatal effects.2
From Academy of Breastfeeding Medicine, Protocol #15. Montgomery A, Hale T, et al. 2006
Other forms of analgesia such as inhaled nitrous oxide, paracervical block, pudendal block and local perineal anaesthesia expose the infant to minimal quantities of medication and may be an alternative to intravenous narcotics or epidural analgesia.
Neuraxial pain relief (epidural/spinal)
Anesthetics such as lignocaine and bupivacaine are commonly administered via the epidural route to mothers in labor to provide pain-free birthing. This local anesthetic is almost always combined with narcotics such as morphine, fentanyl or sufentanil, providing a rapid onset of pain relief while reducing the intensity of immobility for the mother.
While epidurals in labor provide greater pain relief than non-epidural methods, they are also associated with:3
- longer first and second stages of labor,
- maternal fever
- followed by septic work-up of infant, and maternal/infant separation, and possibly antibiotic therapy
- a drop in blood pressure
- fluid 'loading' used routinely; commonly associated with postnatal breast engorgement and additional weight loss in the infant during the first two days
- fluid 'loading' used routinely; commonly associated with postnatal breast engorgement and additional weight loss in the infant during the first two days
- problems passing urine
- an increased use of oxytocin augmentation
- an increased incidence of fetal malposition,
- an increased need for instrumental vaginal delivery
- the mother being unable to move for a period of time after the birth, and
- the possibility of a postdural puncture headache4 palliatively treated by horizontal bed rest, and usually further medical intervention.
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![]() | ![]() Did you know?Another side effect of epidural administration is the fall in maternal serum beta endorphins.7 Beta-endorphins are a naturally occurring opiate that, like other opiates, act as an analgesic, inducing feelings of pleasure, euphoria, and dependency or, with a partner, mutual dependency.
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Cesarean (caesarean) section or vaginal instrumental birth
Cesarean birth is most often associated with delayed skin-to-skin contact between mother and baby and longer time to first breastfeed. Hospitals practicing Step 4 of the 10 Steps to Successful Breastfeeding are, however, diligent at ensuring a minimum disruption to this important bonding and breastfeeding step.
- Rowe-Murray et al (2002)13 reported a significant delay in initiating breastfeeding compared with women giving birth vaginally, with or without instrumental assistance.
- Shawky & Abalkhail (2003)14 found caesarean section delivery to be significantly related to earlier cessation of breastfeeding.
- Leung et al (2002)15 identified caesarean delivery was a risk factor for not initiating breastfeeding, for breastfeeding less than 1 month, and it remained a significant hazard against breastfeeding duration.
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![]() | ![]() Interesting researchAn interesting study16 looked at whether the hormonal patterns of oxytocin, prolactin and cortisol differed between women delivered by emergency cesarean section or vaginally, and if those patterns showed any relation to the duration of breastfeeding. They found that the mothers birthing vaginally had significantly more oxytocin pulses on Day 2 than the cesarean section mothers. Furthermore, the cesarean section women lacked a significant rise in prolactin levels at 20-30 min after the onset of breastfeeding. They were able to link the oxytocin pulsatility on Day 2 to the duration of exclusive breastfeeding.
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Don't forget the effects of the operation itself: an abdominal incision, pain, restricted movement, intravenous therapy, a urinary catheter, analgesics for several days, restricted oral intake and any complications arising from these interventions. Rooming-in is more difficult, at least initially.
The baby has an increased risk of respiratory problems, and is subjected to suctioning of mouth and oropharynx. Some units purposely separate the post-cesarean delivered baby from its mother for "observation" for several hours and may perform routine heel prick blood tests. Due to separation and the desire of the staff to let the mother 'rest', the baby may be given formula supplements.
All of these factors have the potential to limit the frequency, effectiveness and, ultimately, duration of breastfeeding.
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The Natural Caesarean. A wonderful way to support the mother and respect the baby when birth is by caesarean. This 12 minute video is from Youtube. (Some hospitals block youtube - view from a home computer) | ![]() |
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![]() Pregnancy classesWhat is included about birthing interventions in the curriculum of the pregnancy classes where you work? Do all pregnant women know the effects of interventions on themselves and their baby? Do they have to give consent prior to any of these procedures? How well informed is this consent? Form a group to review the pregnancy class curriculum. |
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Assisting a mother following an assisted delivery
- Initiate skin-to-skin contact as soon as possible
- immediately following vaginal delivery if baby does not require advanced life support.
- as soon as possible if caesarean section under epidural or spinal analgesia. Many hospitals facilitate this while the surgeon closes the wound.
- as soon as the mother is responsive if caesarean section under general anaesthetic. Place baby in skin-to-skin contact with father or other close family until mother available.
- If contact must be delayed initiate skin-to-skin contact at the earliest opportunity.
- Assist with breastfeeding as soon as possible.
- The mother does not need to be able to sit up, to hold her baby, or meet other mobility criteria in order to breastfeed.
- It is the baby that is finding the breast and suckling.
- As long as there is a support person with them, the baby can go to the breast if the mother is still sleepy from anesthesia.
- Help the mother find a comfortable position.
- Side-lying in bed. This position helps to avoid pain in the first hours and allows breastfeeding even if the mother must lie flat after spinal anesthesia.
- Sitting up with a pillow over the incision or with the baby held along the side of her body with the arm closest to the breast.
- Lying flat with the baby lying on top of the mother.
- Facilitate rooming-in with assistance, until mother is able to care for baby.
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![]() | ![]() Workbook Activity 4.3Complete Activity 4.3 in your workbook. | ![]() |
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![]() What can you do?
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What should I remember?
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Self-test quiz
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Notes
- # Hale TW (2002) Medications and Mothers' Milk
- # Montgomery A et al. (2006) ABM clinical protocol #15: analgesia and anesthesia for the breastfeeding mother.
- # Anim-Somuah M et al. (2005) Epidural versus non-epidural or no analgesia in labour.
- # Vincent RD et al. (1998) Epidural Analgesia During Labor
- # Rosenblatt DB et al. (1981) The influence of maternal analgesia on neonatal behaviour: II. Epidural bupivacaine
- # Sepkoski CM et al. (1992) The effects of maternal epidural anesthesia on neonatal behavior during the first month
- # Raisanen I et al. (1984) Pain and plasma beta-endorphin level during labor
- # Dabo F et al. (2010) Plasma levels of beta-endorphin during pregnancy and use of labor analgesia.
- # Buckley S (2002) Ecstatic Birth: The Hormonal Blueprint of Labor
- # Ombra MN et al. (2008) beta-Endorphin concentration in colostrums of Burkinabe and Sicilian women.
- # Zanardo V et al. (2001) Labor Pain Effects on Colostral Milk Beta-Endorphin Concentrations of Lactating Mothers
- # Zanardo V et al. (2001) Beta Endorphin Concentrations in Human Milk
- # Rowe-Murray HJ et al. (2002) Baby Friendly Hospital Practices: Cesarean Section is a Persistent Barrier to Early Initiation of Breastfeeding
- # Shawky S et al. (2003) Maternal factors associated with the duration of breast feeding in Jeddah, Saudi Arabia
- # Leung GM et al. (2002) Breast-feeding and its relation to smoking and mode of delivery
- # Nissen E et al. (1996) Different patterns of oxytocin, prolactin but not cortisol release during breastfeeding in women delivered by caesarean section or by the vaginal route